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Article: Progression Risks for Juvenile Idiopathic Scoliosis

Here is an interesting article. One very positive message from this study is that if juvenile curves can be maintained at levels below 20 degrees the chances of avoiding spinal fusion during the adolescent growth spurt are pretty good.

Objectives. To define risk factors of curve progression during pubertal growth and analyze the timing of arthrodesis.

Summary of Background Data. Juvenile scoliosis is characterized by a major, extremely variable progression risk. Peak growth velocity is the most critical period. Curve progression related to growth needs to be analyzed critically for an adequate treatment.

Methods. A total of 205 patients, including 163 girls and 42 boys, with juvenile scoliosis were reviewed at skeletal maturity. The scoliosis was divided into juvenile I with an onset of 4-7 years (52 patients) and juvenile II with an onset of 8-10 years (153). Standing and sitting height, weight, Tanner signs, skeletal age, and menarche were regularly assessed. Topographies and Cobb angles of primary and secondary curves were referred to the pubertal growth diagram.

Results. Of 205 patients, 99 (48.3%) were operated on. Of 109 curves <=20[degrees] at onset of puberty, 15.6% progressed >45[degrees] and were fused. Of 56 curves of 21[degrees] to 30[degrees], the surgical rate increased to 75.0%. It was 100% for curves >30[degrees]. Curves >20[degrees], which increased and were operated on, progressed significantly during peak growth velocity (P = 0.0014). Curves that progressed by 6[degrees] to 10[degrees]/y were fused in 70.9%, curves which increased >10[degrees]/y in 100% of cases (P = 0.0001). This risk was highest for primary thoracic curves: King V, III, and II (P = 0.0001). There was no difference between males and females or juvenile I and II.

Conclusions. Curve pattern, Cobb angle at onset of puberty, and curve progression velocity are strong predictive factors of curve progression. Juvenile scoliosis >30[degrees] increases rapidly and presents a 100% prognosis for surgery (curve >40[degrees] to 45[degrees]). Anticipation is necessary if the scoliosis progresses during the first year of puberty. The prediction is difficult for curves of 21[degrees] to 30[degrees] during the first 2 years of puberty. Curve pattern and curve progression velocity are useful to detect which curves are likely to progress. From this retrospective analysis, spinal fusion could have been indicated earlier sometimes. An earlier intervention is probably preferable to obtain better curve reduction on a supple spine, even if a perivertebral fusion is necessary. We use the 3 parameters for operative indications. If an early spinal fusion leads to better curve correction needs to be verified on prospective data.

Celia,
Remind me when phv occurs. I've been the most concerned that Rachel's curve would take off during her PHV. I don't knowwhen that is . She is probably anywhere from 1 to 2 years from puberty. My period started when I was 13. Sarah's started when she was 12. Rachel will soon be 11.
Thanks!
Cheryl

God has used scoliosis to strengthen and mold us. He's good all the time!On this forum these larger curves have not held forever in Spinecor,with an initial positive response followed by deterioration. With deterioration, change treatment.The first year she gained 4 or 5 inches and was stable at around 20/20 in brace, followed by rapid progression the next year.She is now 51/40 (Jan2008)out of brace (40/30 in Spinecor) and started at 38/27 out of brace(Jan2006.) Now in Cheneau.

I'll have to listen to that SRS presentation by Dr. Vishwas and Dr. Sanders again. I can't remember how long peak height velocity lasts - is it two years My brain is mush right now. I definitely remember PHV ending something like 4 months before menses.

One question I have is whether the *magic* 20 degree number is inbrace correction or not. Doctors don't normally brace curves under 20 degrees and I realize with juvenile scoliosis that some real correction can be expected with growth and the many years of bracing.

I imagine that this study involved conventional rigid bracing and not the revolutionary spinecor brace Rachel is currently wearing - so no need to panic.

It would be encouraging to think that she was right in the middle of her PHV and her curve has at least remained stable on x-ray. Her rotation in brace has increased at every visit. This time, her rotation was 8 in and out of brace. IN April, she was 11 out of brace and six in brace(rotation). In January, she was 11 out of brace and 3 in brace. I can see the increase in rotation.
Dr. Coillard did not seem concerned, but it has me anxious. I thought I would feel home free if this visit was good, but I don't. I know you all understand.

God has used scoliosis to strengthen and mold us. He's good all the time!On this forum these larger curves have not held forever in Spinecor,with an initial positive response followed by deterioration. With deterioration, change treatment.The first year she gained 4 or 5 inches and was stable at around 20/20 in brace, followed by rapid progression the next year.She is now 51/40 (Jan2008)out of brace (40/30 in Spinecor) and started at 38/27 out of brace(Jan2006.) Now in Cheneau.

This study is probably worrying you needlessly because the study is for juvenile idiopathic scoliosis and your daughter has adolescent idiopathic scoliosis. From my limited understanding, rotation for juvenile scoliosis can be a problem because the scoliosis develops over many years and the deformity is structural and rigid by the time the child hits the adolescent growth spurt. This is normally not the case for adolescent idiopathic scoliosis and if you remember... the "magic" number for adolescent idiopathic scoliosis is 30 degrees before PHV.

I don't understand Dr. Rivard's measurement system for rotation. I'm still on the Nash Moe method where they divide the rotation into phases ranging from 1 - 4.

Rachel actually has juvenile idiopathic scoliosis. She has been diagnosed since age 7 or 8. Her curve held at 18 degrees for 2 years and then progressed last year 20 degrees. If I had known about Spinecor when she was first diagnosed, we probably wouldn't be where we are now. Her curve was very gentle then- much more correctable.

God has used scoliosis to strengthen and mold us. He's good all the time!On this forum these larger curves have not held forever in Spinecor,with an initial positive response followed by deterioration. With deterioration, change treatment.The first year she gained 4 or 5 inches and was stable at around 20/20 in brace, followed by rapid progression the next year.She is now 51/40 (Jan2008)out of brace (40/30 in Spinecor) and started at 38/27 out of brace(Jan2006.) Now in Cheneau.

I know how frustrated you must feel! It makes you want to scream !!!! I don't understand doctors in general - don't get me wrong there are some real gems out there that have almost attained god like qualities in my eyes - but they're few and far between. Why some of these men/women go into medicine is questionable as far as I'm concerned.

Rachel is doing great! I would try to find out whether Rachel's rotation is something you should be worried about.

I read the article and it appears that curves under 20 degrees for juvenile scoliosis were not braced! The fact that 75% of curves ranging from 21 to 30 at the onset of puberty progressed to surgery levels tells me that these children were braced too late!!! Maybe there were other things that doctors should have been looking at besides Cobb angle such as rotation, hypokyphosis, RVAD etc during those years of "watching and waiting" that are pointers for progression and these children *may* have avoided surgery. Here is an excerpt:

"...Primary and single lumbar curves have a more benign prognosis. Sagittal plane radiographs were not statistically evaluated in the present study because of incomplete data, but we also believe that a hypokyphotic component of the thoracic segment as well as an increased vertebral rotation must be considered as negative prognostic factors which are part of the 3 dimensional spinal deformity"

I know our orthopedic surgeon would not brace Rachel at 18/18. He said that bracing weakened the trunk muscles and could make the curve worse.
Of course that is with traditional bracing. HE did not even know the Spinecor existed, and I trusted that he was presenting me with all my options until I stumbled across the Spinecor.

With the advent of the Spinecor, I think that they need to look at totally reevaluating their guidelines for bracing. You could brace a lot of children for what one surgery costs, even if you are using that as your plumbline(which is what insurance companies do)

It would make sense to see if the Spinecor could correct a large percentage of these curves before they ever had a chance to progress. I suppose as the brace proves itself, maybe the medical community will change.......... I am afraid it will take way too much time and many children will suffer.
Most doctors are very slow to change.

Last edited by cherylplinder; 09-02-2006 at 09:11 AM.

God has used scoliosis to strengthen and mold us. He's good all the time!On this forum these larger curves have not held forever in Spinecor,with an initial positive response followed by deterioration. With deterioration, change treatment.The first year she gained 4 or 5 inches and was stable at around 20/20 in brace, followed by rapid progression the next year.She is now 51/40 (Jan2008)out of brace (40/30 in Spinecor) and started at 38/27 out of brace(Jan2006.) Now in Cheneau.